Evaluation of hemoptysis

Hemoptysis is the coughing of blood from a source below the glottis.[1]Stoller JK. Diagnosis and management of massive hemoptysis: a review. Respir Care. 1992 Jun;37(6):564-81. http://www.rcjournal.com/contents/06.92/06.92.pdf It can range from a small amount of blood-streaked sputum to massive bleeding with life-threatening consequences due to airway obstruction, hypoxemia, and hemodynamic instability.

In a study of patients in primary care, the incidence of hemoptysis was found to be 1 case in 1000 patients per year.[2]Jones R, Charlton J, Latinovic R, et al. Alarm symptoms and identification of non-cancer diagnoses in primary care: cohort study. BMJ. 2009 Aug 13;339:b3094. https://www.bmj.com/content/339/bmj.b3094.long http://www.ncbi.nlm.nih.gov/pubmed/19679615?tool=bestpractice.com Massive hemoptysis occurs in around 5% to 15% of patients presenting with hemoptysis.[3]Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration. 2010 Jan 8;80(1):38-58. https://www.karger.com/Article/FullText/274492 http://www.ncbi.nlm.nih.gov/pubmed/20090288?tool=bestpractice.com The rate of bleeding is the most important factor determining mortality.[4]Holsclaw DS, Grand RJ, Schwachman H. Massive hemoptysis in cystic fibrosis. J Pediatr. 1970 Jun;76(6):829-38. http://www.ncbi.nlm.nih.gov/pubmed/5444576?tool=bestpractice.com

Massive hemoptysis

Various definitions of massive hemoptysis exist. A common definition is the expectoration of blood from a source below the glottis exceeding 600 mL of blood over a 24-hour period or 150 mL of blood (which may flood the lung dead space) over a 1-hour period. However, quantifying blood loss accurately can be a challenge.

Massive hemoptysis can also be defined by its clinical effect:[3]Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration. 2010 Jan 8;80(1):38-58. https://www.karger.com/Article/FullText/274492 http://www.ncbi.nlm.nih.gov/pubmed/20090288?tool=bestpractice.com

• Airway compromise: obstruction, aspiration, hypoxemia, need for intubation

• Hemodynamic instability

• Requirement for blood transfusion.

Massive hemoptysis is a medical emergency and should be addressed immediately. Initial priorities are stabilization of the patient and protection of the nonbleeding lung.

Common causes

Hemoptysis has numerous possible causes, including tracheobronchial, pulmonary parenchymal, and pulmonary vascular diseases. In the primary care setting, major causes are acute and chronic bronchitis, tuberculosis, lung cancer, pneumonia, and bronchiectasis.

Pseudohemoptysis versus hemoptysis

The initial diagnostic evaluation should aim to differentiate between hematemesis (i.e., the vomiting of blood), pseudohemoptysis (i.e., the coughing of blood from a source other than the lower respiratory tract), and hemoptysis. Pseudohemoptysis can occur when:[5]Lyons HA. Differential diagnosis of hemoptysis and its treatment. Basics Respir Dis. 1976;5:26-30.

• Hematemesis is aspirated into the lungs

• Bleeding from the upper airway or the mouth stimulates a cough reflex

• Material is expectorated that looks like blood but is not (e.g., Serratia marcescens infection).

Characteristically, hemoptysis tends to be indicated by bright red, frothy sputum that is alkaline.

Blood from extrapulmonary sources tends to be darker, may have admixed food particles, and is acidic.[5]Lyons HA. Differential diagnosis of hemoptysis and its treatment. Basics Respir Dis. 1976;5:26-30.[6]Comforti J. Management of massive hemoptysis. In: Simoff MJ, Sterman DH, Ernst A, eds. Thoracic endoscopy: advances in interventional pulmonology. Malden, MA: Blackwell Publishing; 2006:23:330-43. The exception is when brisk bleeding in the gastrointestinal tract overcomes the acidic environment of the stomach.

Bleeding from the posterior nasal passage or nasopharynx may mimic hemoptysis without obvious epistaxis. Examining the oral and nasal cavities can provide important clues to the source of the bleeding (e.g., telangiectasia in the mouth or nose, etc.).